THE LINK BETWEEN SOMATIC AND PSYCHOLOGICAL SEQUELAE OF TRAUMATIC VAGINAL BIRTH

Abstract

Aims and overview This thesis investigates first time mothers’ experiences of vaginal childbirth, that resulted in female pelvic organ prolapse (FPOP), fecal incontinence and sexual dysfunction, to identify links with adverse postpartum psychological health. Although vaginal delivery is widely portrayed as an empowering event with positive outcomes, modern imaging methods reveal 10-30% of women sustain irreversible pelvic floor injury that is commonly overlooked. A major factor in the causation of FPOP is detachment of the levator ani muscle (LAM) from insertion site(s) on the os pubis, during lengthy second stages of labour that involve forceps to deliver large babies. Such injuries are likely to be associated with psychological trauma from resultant symptoms of pelvic floor and sexual dysfunction that impair quality of lifestyle. The link between somatic and psychological trauma is poorly understood. Methods Mixed methods enquiry focused on qualitative methodology to explore the experiences of a cohort of primiparous women, diagnosed with LAM injury using semi-structured interviews. Participants were selected from quantitative pelvic floor imaging studies. Respective data facilitated accuracy regarding birth damage. The interviewer was a midwife with extensive professional experience. Maternal themes from this study generated additional enquiries that involved: quantitative and mixed methods analyses regarding the efficacy of a routine postnatal depression (PND) screening instrument in identifying the symptoms of postpartum posttraumatic stress disorder (PTSD) for injured women; a mixed methods approach to explore partners’ understanding of birth injury sequelae related to maternal sexual dysfunction; appraisal of current research literature for insight into birth-related anatomy and physiology of the pelvic floor and Somatic and psychological vaginal birth trauma 10 perineum; review of historical commentaries and sources on the origins of vaginal birth injury, PTSD and natural birthing methods for associations with present maternity care. Results More than two thirds of women in the focal study, experienced emotional trauma symptoms, similar to PTSD, as per DSM-5, usually ascribed to war veterans. Contributing factors seemed to challenge contemporary maternity practice. Mothers stated antenatal classes overemphasized natural birthing methods and omitted risk factors of vaginal birth that “…set [them] up for failure”. As a consequence, they were ill-prepared for complicated deliveries, resultant injuries and enduring morbidities that, clinicians dismissed as normal sequelae of birth. During unexpected high acuity births, women reported overt conflict between midwives and doctors regarding mode of delivery. After discharge from maternity units, they were confronted with suboptimal diagnoses of injuries, ineffective identification of postpartum PTSD symptoms, barriers to somatic and mental health care treatment and marital disharmony. Original study findings revealed that routine PND measures were not useful in diagnosing symptoms of PTSD for this cohort of women. Interviewed men were observed to lack understanding of links between somatic injury, sexual dysfunction and emotional trauma. Appraisal of literature on the pelvic floor and perineum demonstrated substantial imaging research on the etiology, risk factors and prevalence of diverse injuries that included LAM damage and, the more accepted obstetric anal sphincter injuries (OASI). Historical review revealed natural childbirth methods currently promoted in birth classes, and often used exclusively in birthing suites, are unproven theories from another century. Despite increasing literature on somatic vaginal birth injury and postpartum PTSD over the past decade, both of these risk factors of vaginal birth were shown to be largely overlooked. Conclusions This thesis is a significant contribution to the body of knowledge on sequelae of traumatic vaginal birth. Women’s narratives, revealed a strong link between somatic and psychological birth trauma that was reported to be poorly understood by obstetricians, midwives and perinatal mental health clinicians. A key recommendation, is that prior to vaginal delivery, women and their partners are Somatic and psychological vaginal birth trauma 11 informed of inherent risk factors and given unbiased education. This can only occur, if research on LAM damage and sequelae of postpartum PTSD, are integrated into clinical practice. There is an urgent need for maternity clinicians to implement evidence-based guidelines that aim to: decrease adverse birth-related sequelae; facilitate diagnostic imaging assessment; and identify emotional trauma symptoms. At present, the relationship between vaginal and psychological birth trauma is poorly recognized and has debilitating consequences for women, partners and babies. Key words: birth trauma; female pelvic organ prolapse; levator ani muscle avulsion; postpartum posttraumatic stress disorder; primiparous women; vaginal birth